CurrentBlue Cross Blue Shield - MainePolicy N/A

Statutorily non-covered services for Medicare Advantage members

Governs how Blue Cross Blue Shield - Maine handles services excluded from Medicare statute for Medicare Advantage members, including notification, billing modifiers, and member/provider responsibilities.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyStatutorily non-covered services for Medicare Advantage members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest a Notice of Denial of Medical Coverage (NMDC) from the Medicare Advantage plan before providing a statutorily non-covered service and include the NMDC with the claim.

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

GX & GYrequired claim modifiers for statutorily excluded services

NMDCplan-issued letter required

ProhibitedABN status

Requiredclaim filing

Coverage for Statutorily Excluded Services

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Coverage criteria and billing/notification rules

Statutorily excluded services for Medicare Advantage members — policy stance and provider billing/notification rules.

ALL of the following

Member may be held liable for the never-covered service or item per the EOC
Contracted providers should contact the Medicare Advantage plan with questions or request a Notice of Denial of Medical Coverage (NMDC)
Provider may submit the claim with an appropriate G modifier (GX or GY) as configured

ALL of the following

Member must follow supplemental benefit vendor guidelines per the EOC (for example routine vision, hearing, dental)
Provider should contact the plan to confirm coverage or request an NMDC prior to providing the service

ALL of the following

Contracted providers are considered agents of the Medicare Advantage plan and are responsible for ensuring CMS-required notification has been met
The Medicare Advantage plan must issue the NMDC; providers may not issue their own NMDC templates
If an NMDC is not given to the MA member as required, the claim may be denied to the provider and the member cannot be held financially liable

ALL of the following

The NMDC is mailed to the member and a copy is faxed to the provider; providers should submit the NMDC with the claim
Claims should be submitted for all services rendered even when an NMDC has been issued; submission with appropriate modifiers is required for appeals

ALL of the following

Do not use the Advanced Beneficiary Notice (ABN) for Medicare Advantage members; CMS prohibits ABN use for MA — the plan-issued NMDC must be used instead

Modifiers, Codes, and Required Request Information

G-modifier usage for statutorily excluded servicesModifier | mixedCovered

GX	Item or service statutorily non-covered or is not a Medicare benefit. Use = Use for statutorily excluded services. The contracted provider is to submit the claim with a GX modifier.
GY	Item or service statutorily non-covered or is not a Medicare benefit and proper notification has been secured. Use = Use for statutorily excluded services when a Notice of Non-Coverage has been issued. The contracted provider is to submit the claim with a GY modifier.
GY	Item or service statutorily non-covered or is not a Medicare benefit and proper notification has NOT been secured. Use = Use for statutorily excluded services when the EOC is clear that the item is never covered.
GZ	Indicates that it is expected that Medicare will deny a service as not reasonable and necessary with no advanced notice. Use = Not appropriate on statutorily excluded services.
GA	Indicates that it is expected that Medicare will deny a service as not reasonable and necessary. Use = Not appropriate on statutorily excluded services.

Required information when requesting NMDC

Member identifierMember ID including prefix

Service dateDate of Service (DOS)

Member demographicsMember name and date of birth (DOB)

Servicing provider detailsServicing provider name and TIN

Ordering physician detailsOrdering physician name, address and TIN

Servicing facility detailsServicing facility name, address and TIN

Claim/contact info and clinical codesFax number for the servicing provider; CPT code(s); diagnosis

Provider Responsibilities and Claim Submission

Denial Risk

Requesting Notice of Denial of Medical Coverage

Providers must request a Plan-issued Notice of Denial of Medical Coverage (NMDC) from the Medicare Advantage plan before providing a statutorily non-covered service. The NMDC must be issued by the plan to the member (mailed) and a copy faxed to the provider. If the NMDC is not obtained and provided to the member, the claim may be denied and the provider will be held financially responsible.

When a member requests a statutorily excluded service, the contracted provider should call the Plan's Provider Service/Customer Service Department and request issuance of a Notice of Denial of Medical Coverage letter prior to rendering the service.
Provide the following info when requesting the NMDC: Member ID (including prefix), member name and DOB, date of service, servicing provider/TIN, ordering physician/address/TIN, servicing facility/address/TIN, fax number for the servicing provider, CPT code(s), and diagnosis.
The Plan will mail the NMDC to the member and fax a copy to the provider.
The NMDC advises the member the service is not covered, documents the member’s financial liability if they choose to proceed, and explains appeal rights.
The Plan must issue the NMDC; providers are not permitted to issue their own NMDC templates to MA members.
Always submit the NMDC with the claim when filing for a statutorily excluded service so the claim can be processed correctly.
If there is any doubt whether a service is not covered, request a coverage determination / NMDC from the Plan before providing the service.

Billing Rule

Claim Modifiers and Submission

Submit claims for statutorily non-covered services with the Anthem-configured modifiers and include the NMDC when issued. Do not use an Advance Beneficiary Notice (ABN) for Medicare Advantage members; ABNs are not valid for MA enrollees.

Use GX to indicate the item or service is statutorily non-covered or is not a Medicare benefit (use for statutorily excluded services).
Use GY when the item or service is statutorily non-covered and proper notification has been secured (i.e., an NMDC has been issued).
Do not use GA or GZ for statutorily excluded services per Anthem configuration guidance.
Attach/submit the NMDC with the claim when it was issued prior to the service.
File claims for all services rendered even if an NMDC was issued; if the member appeals, a claim with the appropriate modifiers must exist.

Key Terms

Examples of services excluded from Medicare coverage by statute

Eye refractionsEye refractions with the Medicare covered vision exam

Hearing aidsHearing aids

Custodial careCustodial care

Routine dental and vision servicesRoutine dental services; routine vision services

Services outside the U.S.Service not provided within the United States

Notice of Denial of Medical Coverage (NMDC)

DefinitionPlan-issued letter advising the member the service is not covered, that they are liable for payment, and their appeal rights

Who issues itMust be issued by the Medicare Advantage plan per CMS guidelines (MA organization/health plan issues the letter); providers may request it from Provider Service

Delivery and useLetter is mailed to the member and a copy is faxed to the provider; the NMDC should be submitted with the claim

Consequence of no NMDCIf the NMDC is not given to the MA member, the claim may be denied and the provider may be held financially responsible

Advanced Beneficiary Notice (ABN) and Medicare Advantage

DefinitionAdvanced Beneficiary Notice (ABN) is used in Medicare Fee‑for‑Service to notify beneficiaries about potential payment liability

MA prohibitionCMS prohibits the use of the ABN for Medicare Advantage members; ABN is not used for items or services under the MA program

Required alternativeMedicare Advantage providers must use the Plan-specific Notice of Denial of Medical Coverage (NMDC) instead of the ABN

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyStatutorily non-covered services for Medicare Advantage members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest a Notice of Denial of Medical Coverage (NMDC) from the Medicare Advantage plan before providing a statutorily non-covered service and include the NMDC with the claim.

SourceLink

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